Hindawi Journal of Environmental and Public Health Volume 2019, Article ID 5490716, 8 pages https://doi.org/10.1155/2019/5490716

Research Article Diarrhea Prevention Practice and Associated Factors among Caregivers of Under-Five Children in Enemay District, Northwest Ethiopia

Melese Dubie Agegnehu,1 Liknaw Bewket Zeleke ,2 Yitayal Ayalew Goshu ,3 Yonas Lamore Ortibo,2 and Yohannes Mehretie Adinew 4

1World Vision, Addis Ababa, Ethiopia 2College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia 3College of Health Sciences and Medicine, Debre Tabor University, Debre Tabor, Ethiopia 4College of Health Sciences and Medicine, Wolaita Sodo University, Ethiopia

Correspondence should be addressed to Liknaw Bewket Zeleke; [email protected]

Received 24 October 2018; Revised 2 February 2019; Accepted 11 February 2019; Published 12 May 2019

Academic Editor: Pauline E. Jolly

Copyright © 2019 Melese Dubie Agegnehu et al. .is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Diarrhea is the leading cause of mortality among infants and children younger than 5 years of age in both un- derdeveloped and developing countries. Factors determining the occurrence of diarrhea in children are complex, and the relative contribution of each factor varies as a function of interaction between socioeconomic, environmental, and behavioral variables. Objectives. To assess diarrhea prevention practice and associated factors of diarrheal disease among caregivers who have under- five children in Enemay district, Ethiopia, 2018. Methods. Community-based cross-sectional study was done from June 1–30, 2018, among 398 caregivers who have under-five children, in the Enemay district that were selected by using the simple random sampling technique. A structured and pretested data collection tool was used to collect the data. Data were entered using EPI DATA version 4.2, and analysis was done using SPSS version 20 statistical package to be cleaned and analyzed. Descriptive analysis was done to describe study participants, and logistic regression (bivariable and multivariable) analysis was done to identify factors that have association with the dependent variable. .e P value was less than 0.05. Results. A total of 398 with a response rate of 97% under-five caregivers were participated in this study. Nearly, half (48.7%) of the participants were in the age group 25–34. .e study revealed that good practice of diarrhea prevention was 52.8%. .is study was also identified that occupation (AOR: 3.922, 95% CI: 1.593, 9.657), family size (AOR: 0.088, 95% CI: 0.009, 0.916), and understanding on diarrhea (AOR: 0.237, 95% CI: 0.091, 0.613) were associated factors of diarrhea prevention practice of under-five children caregivers. Conclusion. .is finding showed that diarrhea prevention practice among under-five children caregivers was low and prevention practice was significantly as- sociated with caregivers’ awareness on frequency of diarrhea in a day, occupation, and family size in a house.

1. Background Diarrhea is the second leading cause of child morbidity and mortality, especially in the developing countries. Glob- Diarrhea is the passage of loose or watery stools occurring ally, it is estimated that there are 2.5 billion episodes and 1.5 three or more times in a 24-hour period which means an million deaths annually in children under five years [3]. increased frequency or decreased consistency of bowel Diarrheal diseases are major causes of malnutrition, movements, and it affects people of all ages [1]. It is usually delayed physical development, and early childhood mor- a symptom of an infection in the intestinal tract, which can tality in developing countries and poor communities, and be caused by a variety of bacterial, viral, and parasitic or- the major cause of death in children with diarrhea is loss of ganisms [2]. water and essential minerals [4]. 2 Journal of Environmental and Public Health

In sub-Saharan Africa, primary caregivers display poor With confidence level 95% and margin of error 5%, 2 2 perception about the signs of dehydration, dysentery, and n � (Zα/2) p(1 − P)/d , where n is the sample size, P is the management of diarrhea [5]. population proportion of diarrhea prevalence, d is the .e incidence of illnesses contributing to avoidable deaths margin of error (0.05), and α is 5%. diarrhea is higher in Ethiopia compared to other sub-Saharan So using the above formula, the sample size is African countries partly due to different factors [6]. In n � z2p((1 − p)/d2) Ethiopia, diarrheal disease is a major public health problem, � ((1.96)2 × 0.413)((1 − 0.413)/(0.05)2) � 373. and it is one of the top 15 countries in which nearly three- .e final sample size with 10% nonresponse rate is 410. fourths of child deaths occur due to diarrhea [4]. In Ethiopia, morbidity reports and community-based studies indicate that 2.5. Sampling Technique. .e study was conducted using diarrheal diseases are a major public health problem that simple random sampling. Six kebeles were selected by lottery causes excess morbidity and mortality among children [7]. method from all 29 kebeles in the Enemay district. Finally, .e prevalence in Enemay woreda is 18.6% which indicates the required number of under-five caregivers was selected by diarrhea is still the burden in the study area [8]. using the simple random sampling technique from the list Various preventive techniques were reported in the obtained from health extension workers in selected kebeles. literatures including hygiene and sanitation, diet, medica- tions, and supplements which are generally classified as health care, breastfeeding, immunization, supplemental 2.6. Data Collection Procedure. Data were collected by in- zinc, and probiotics [9]. Treatment and prevention of di- terviewer-administered interview and observation using arrhea can be done at home by primary caregivers, and their semistructured questionnaire. .e questionnaire was pre- role is vital in health promotion, disease prevention, and pared in English initially by reviewing the literatures and patient care [4]. then translated in to the Amharic version which later on Prevention practice of caregivers is important and can translated back to the English version to check its consis- prevent diarrhea-related child morbidity and mortality. tency and comparability of the finding. Six health extension .erefore, the study aimed at identifying the gaps on under-five data collectors and one BSc nursing supervisor were children diarrhea prevention practice and associated factors in recruited to data collection in the Enemay district. Training the study area so as to forward recommendations for under- was given for data collectors and supervisor on objectives of five caregivers, local health-care providers, and other stake- the study, method of collecting the needed information holders to reduce diarrhea-related morbidity and mortality. through interviewing and observation, how to fill the in- .e community at large in the study area can be benefited from formation on the questionnaire, and the ethical aspect in improved under-five diarrhea prevention practice. approaching the participants which should be in a polite and respectful manner. .e supervisor had been monitoring the 2. Methods data collection process, and the investigators were available to respond the concerns raised from the data collector and 2.1. Study Design. Community-based cross-sectional study the supervisor. .e older children were considered when two was conducted. or more under-five children were found in the house.

2.2. Study Area and Period. .e study was conducted in 2.7. Operational Definition Enemay district, East Gojjam zone, Amhara regional state, 2.7.1. Good Diarrhea Prevention Practice. Participants who northwest Ethiopia, from June 1–30, 2018. .e Enemay scored above the mean value of practice question [11]. district is located 370 km, northwest of Addis Ababa, the capital city of Ethiopia, and 220 km southwest of Bahir Dar city, the capital of the Amhara National Regional State, re- 2.7.2. Clean Latrine. No fecal matter in and around the pit spectively. .e total population in the district is 198241, of latrine, properly swept. which 26404 are under-five children. .e district has one district hospital, 7 health centers, and 34 health postsites. All 2.7.3. Hand Washing at Critical Time. It includes washing these health facilities involve in diarrhea prevention and hand after using a toilet, after cleaning a child, after any control. Access to safe water supply in the district is 62% [10]. cleaning activity, before preparing food, before meal, and before breastfeeding. 2.3. Source Population. All caregivers of under-five children in the Enemay district were the source populations, and the 2.7.4. Caregiver. A caregiver is an individual who could be study population was all caregivers of under-five children in a parent, foster parent, or head of the household who attends the selected kebeles. to the needs of a child or primary caregiver [12].

2.4. Sample Size Determination. Single population pro- 2.8. Data Quality Assurance. .e questionnaire was adapted portion formula was employed using population proportion from literatures and modified into local context. Training 41.3% [5]. was given for data collectors and supervisor. Pretesting of the Journal of Environmental and Public Health 3 questionnaire was made on 5% of the sample size in adjacent for caregivers about causes of diarrhea, and 70.1% respond kebele prior to the actual data collection. .e data collection contaminated food. Concerning treatment seeking behavior process was strictly followed day to day by the supervisor, of the participants, 37 (31.9%) participants stay at home and data were checked for its completeness by the principal without treatment when their child had diarrhea (Table 2). investigator. During analysis, not eligible variables for the analysis method were excluded by checking the chi-square 3.3. Attitude towards Diarrhea Prevention Practice. About test, and the model fitness test was also computed. 252 (60.6%) participants disagreed on the likelihood of their child to get diarrhea in the next month whereas one hundred 2.9. Data Analysis Technique. Data were coded and entered fifty eight (37.7%) of caregivers disagreed that diarrhea is into EPI DATA version 4.2 and exported to SPSS version 20 normal in children. About 166 (39.2%) of caregivers agreed for statistical analysis. Descriptive analysis was done to that diarrhea is a preventable disease, and 110 (27.6%) of describe study participants in terms sociodemographic caregivers disagreed that diarrhea is a preventable disease. characteristics. Bivariate logistic regression analysis was Among the total participants, nearly half (50.5%) agreed that done to determine the association between each in- diarrhea is a communicable disease and 41.5% of caregivers dependent and dependent variable. All factors that were strongly agreed that diarrhea can be caused by open associated with the dependent variable in bivariate analysis defecation. with a P value of 0.20 or less were included in the beginning of multivariable analysis to identify the associated variables. 3.4. Environmental Factors. From the total study partici- A P value < 0.05 and corresponding 95% CI of odds ratio pants, nearly two-thirds (68.8%) had latrine in their premise were considered to declare a result as statistically significant from which almost half (50.4%) were unimproved. Con- in this study in multivariable regression. .e odds ratio cerning hand washing facility, 147 (36.9%) participants had together with 95% confidence intervals was used to interpret hand washing facility in their premise during study period. the strength and direction of association. Nearly one out of five participants (80.2%) of caregivers obtain drinking water from well-protected source and 2.10. Ethical Consideration. Ethical clearance was obtained around half (55%) of caregivers spend longer than from Ethical Review Committee, College of Health Sciences, 30 minutes (round trip) to obtain their drinking water. Debre Markos University, and letter of permission was obtained from the Enemay district health office. .e purpose 3.5. Under-Five Caregivers’ Diarrhea Prevention Practice. of the study was explained to respondents, and verbal in- Two hundred forty nine (62.6%) of the participants treat formed consent was obtained from participants. Confi- their drinking water source using chlorine, and 233 (58.4%) dentiality of information was maintained by keeping of participants use latrine for defecation. From the total anonymous personal identifiers. Children who were found study participants, under-five caregivers asked about hand with active diarrheal disease during house-to-house visit for washing times, 272 (68.3%) respond that they wash their data collection were linked to health facilities for treatment. hands after toilet visit and only 151 (37.9%) wash their hands before child feeding. One hundred sixty four (41.2%) 3. Results caregivers wash their hands using only water. Only 27% latrines were clean during data collection. About half 3.1. Sociodemographic Characteristics. A total of 398 under- (50.5%) of caregivers feed their child exclusively for six five children caregivers participated in the study, making the months (Table 3). response rate of the study as 97%. Among the respondents, As shown by the figure below, the overall diarrhea nearly half (48.7%) were between 25–34 years with the mean prevention practice among caregivers’ of under-five children age of 33.2. Around two-thirds of the participants (66.1%) in the Enemay district, Amhara regional state, northwest and their husband (65.1%) had no formal education. Ethiopia, was 52.8%. Concerning occupation of the participants, majority (87.2%) participants were housewives. Regarding family size, 228 (57.3%) participants had less than four family members per 3.6. Factors Associated with Diarrhea Prevention Practice. household and 392 (98.5%) of caregivers had less than two Factors associated with diarrhea prevention were identified under-five children. (Table 1) by computing bivariate and multivariate analyses. Occu- pation, knowledge on immunization to prevent diarrhea, family size, information on diarrhea, and fluid importance 3.2. Knowledge on Diarrhea Prevention Practice. Out of 398 during diarrhea sickness and awareness of diarrhea fre- caregivers, 62.6% had information on diarrhea and nearly quency showed association in bivariate analysis whereas in one-third (34.4%) of the participants recognized diarrhea as multivariable analysis, occupation of caregivers, family size, passage of watery stool once in a day. More than half of the and awareness on diarrhea frequency showed significant caregivers considered latrine utilization (54.8%) and hand association. washing (51.5%) as prevention methods for diarrhea. In Under-five diarrhea prevention practice among house- addition, 261 (65.6%) of caregivers respond watery diarrhea wives was 3.9 times more likely (AOR: 3.922, 95% CI: 1.593, as sign and symptoms of diarrhea. Questions were also asked 9.656) than merchants and others. 4 Journal of Environmental and Public Health

Table 1: Distribution of sociodemographic characteristics of study caregivers’ in Enemay district, northwest Ethiopia, 2018. Variable name Category Frequency Percent 15–24 50 12.6 Age 25–34 194 48.7 >35 154 38.7 Male 8 2.0 Sex Female 390 98.0 Orthodox 294 73.9 Religion Muslim 103 26.1 Housewife 347 87.2 Student 7 1.8 Occupation Employed 11 2.8 Merchant 33 8.3 No formal education 263 66.1 Education Primary (1–8) 111 27.9 Secondary (9–12) and above 24 6.0 No formal education 259 65.1 Husband education Primary (1–8) 119 29.9 Secondary (9–12) and above 20 5.0 <4 228 57.3 Family size 5–8 170 42.7 1-2 392 98.5 No. of 5 < children 3-4 6 1.5 Mother 301 75.6 Relation to child Sister 89 22.4 Father 8 2 1401–2350 215 54 2351–5000 131 33 Average monthly income >5000 5 1.2 No income 47 11.8 Single 11 2.8 Marital status Married 382 95.9 Divorced 5 1.3

Diarrhea prevention practice in caregivers with family finding in Farta Woreda, northwest Ethiopia, where only size 5–8 was 91.2% less likely (AOR: 0.088, 95% CI: 0.009, 4.9% of the participants treat their drinking water and lower 0.916) than those that have family size less four. than a finding in Dejene woreda, Ethiopia, where 81% add Caregivers who perceived diarrhea as passage of watery bleach to treat drinking water [6, 15]. .e difference might stool two times in a day were 76.3% less likely (0.091, 0.613) be due to sociodemographic factors, accessibility of supplies, to practice diarrhea prevention in under-five children than and difference in study period. who perceived three times in a day (Table 4). In this study, 41.2% of caregivers wash their hands using only water which may not be effective in removing of dis- 4. Discussion ease-causing bacteria, and it could be source of contami- nation during washing their hand which is another risk for From the total participants of the study, 58.4% were utilizing diarrhea transmission. .e reported practice of hand latrine properly. .e findings are in line with the study in washing is slightly higher than the observed availability of Gulomekada District, north Ethiopia, where rate of latrine hand washing facility. .e disparity may be resulted from utilization was about 57.3% [13]. .is finding is higher than utilization of traditional methods of hand washing without a study finding reported from Farta Woreda, northwest preparing or availing hand washing facilities. In the other Ethiopia, where latrine utilization habit was 29.2%, and case, hand washing with soap was lower (26.4%) than with Asmara, Eritrea, which indicated 72.2% of participants are plain water. .e discrepancy might be due to unaffordability defecating in open field [6, 14]. .e difference might be for frequent buying of soap. Similar finding was reported by attributed to the difference in the sociodemographic char- a study carried out in India that demonstrated 41% hand acteristics and basic environmental infrastructure of study washing is with using water only [16]. .is finding is less households, behaviors of the participants, and awareness of than the study conducted in Farta, Ethiopia, where 56.3% of the community. the respondents used only water to wash their hands [6]. .e .e present study revealed that 62.6% of caregivers use difference might be due to sociodemographic and economic chlorine-treated drinking water. .is is higher than a study factors. Journal of Environmental and Public Health 5

Table 2: Knowledge distribution of caregivers about under-five diarrhea prevention in Enemay district, northwest Ethiopia, 2018. Variable name Category Frequency Percent Yes 249 62.6 Information on diarrhea No 149 37.4 Watery diarrhea once in a day 137 34.4 Watery diarrhea twice in day 95 23.9 Awareness on frequency of diarrhea Watery diarrhea three times in a day 78 19.6 Watery diarrhea four times in a day 88 22.1 Vomiting 118 29.6 Fever 130 32.7 Dehydration 163 40.9 Sign and symptom of diarrhea Appetite loss 176 44.2 Weakness 144 36.2 Watery diarrhea 261 65.6 Insects 99 24.9 Contaminated water 262 65.8 Contaminated food 279 70.1 Cause of diarrhea Bad sprit 76 19.1 Poor sanitation 197 49.5 Bad smell 64 16.1 Bloody 116 29.1 Type of diarrhea you know Watery with no blood 282 70.9 No treatment 37 31.9 Homemade ORS 33 28.4 Diarrhea treatment Took to health facility 36 31.1 Visit traditional healer and others 10 8.6 Breastfeeding 173 43.5 Eat safe food 202 50.8 Prevention of diarrhea Use latrine 218 54.8 Immunization 182 45.7 Hand washing 205 51.5

Table 3: Under-five caregivers’ diarrhea prevention practice in Enemay district, northwest Ethiopia, 2018. Variable name Category Frequency Percent Boiling 95 23.9 Chlorine 249 62.6 Water treatment Filter with close 14 3.5 Nothing 40 10.1 After toilet visit 272 68.3 Before food preparation 199 50 Before meal 259 65.1 Hand washing After any cleaning 212 50.3 Before feeding/breastfeeding 151 37.9 After child cleaning 139 9.8 Water only 164 41.2 Hand hygiene materials Water with ash 129 32.4 Water with soap 105 26.4 Yes 200 73.0 Was the latrine clean? No 74 27.0 >6 month 127 31.9 Exclusive breastfeeding 6 month 251 63.1 <6 month 20 5.0 Completed 354 88.9 Immunization status Not completed 44 11.1 Within 1 hour 282 70.8 Initiation of first breast milk After 1 hour 116 29.2 6 Journal of Environmental and Public Health

Table 4: Factors associated with under-five diarrhea prevention practice among caregivers, Enemay district, Ethiopia, 2018. Prevention Variables practice COR (95% CI) AOR (95% CI) Poor Good Immunization Yes 91 91 1.23 (0.49, 0.91) 1.17 (0.71, 1.94) Prevent diarrhea No 6 97 119 1 1 House wife 168 179 1.27 (1.01, 1.59) 3.92 (1.59, 9.66)∗ Occupation Merchants and others 20 31 1 1 ≥5 61 109 0.45 (1.33, 2.89) 0.09 (0.01, 0.92)∗ Family size ≤4 127 101 1 1 Yes 127 122 0.67 (0.44, 0.99) 0.1.503 (0.86, 2.64) Information on diarrhea No 61 88 1 1 Once/twice/day 96 136 0.64 (1.61, 7.67) 0.24 (0.09, 0.61)∗ Frequency of diarrhea >/ � times/day 87 79 1 1 Yes 111 114 1.71 (1.15, 2.55) 1.111 (0.65,1.90) Fluid during diarrhea No 77 96 1 1 ∗Significantly associated; COR, crude odds ratio; AOR, adjusted odds ratio.

In this study, caregivers were asked about hand washing occupation was significantly associated with diarrhea pre- at critical times, and from the total participants, 65.1% wash vention practice [21]. .e reason may be that housewives their hands before meal, 50% wash their hands before food could have the opportunity to get information from different preparation, 37.9% wash their hands before feeding children, sources as they have sufficient time to gain information from 9.8% wash their hands after cleaning children, 50.3% wash different sources and to practice it. .is finding is different their hands after any cleaning activity, and 68.3% wash their from the study conducted in Fagita Lekoma district, hands after visiting toilet. Ethiopia, where occupation was not significantly associated .e present study revealed that about 73% latrines were with diarrhea prevention [22]. .is difference might be due clean. .is is line with the study conducted in Aneded to level of education, sociodemographic status, and socio- District, northwest Ethiopia, where about 66.7% of latrines cultural characteristics. were clean [17]. .is might be due to similar sociodemo- In this study, caregivers who had 5 or more family size graphic status of the community. were 91.2% less likely to practice diarrhea prevention in .e findings of this study revealed that 63.1% of care- under-five children than those who had less than four family givers practiced exclusive breastfeeding for six months. .is size. .is finding is in agreement with a study finding from finding is different from that of the study conducted in Gojam Hullet Ejju Ense woreda, Ethiopia, where greater Jigjiga District, Somali Region, eastern Ethiopia in which family size was associated with diarrhea morbidity [23]. But 84.4% of the children were not exclusively breastfed in the contradicts from a study finding in Derashe District, first 6 months of their life and in 33.6% in Ibadan, Nigeria Southern Ethiopia, where family size was not significantly [7, 18]. .e difference might be due to sociodemographic associated with diarrhea disease [20]. .e difference might factors and difference in study design. be socioeconomic status, environmental factors, education .is study also found that about 88.9% of children level, living condition, and difference in time of study. completed their course of vaccination. .is study is different Caregivers who respond frequency of diarrhea two times from a study conducted in Dejen district, northwest were 76.3% less likely to practice than who answered three Ethiopia, where only 48.6% were fully vaccinated [15]. .e times in a day. .is is the finding supported by the study difference might be due difference level of awareness, ac- conducted in Ethiopia where mothers who had no un- cessibility of health facility, and supplies. derstanding about diarrhea were by 80.3% less likely to have In this finding, about 52.8% of caregivers scored above good practice compared with their counterparts [22]. .is the mean value of practice-related questions that had good may be due to the fact that mothers who had information diarrhea prevention practice. .is is lower than from a study about diarrhea have a good opportunity to good prevention conducted in Indonesia where 68.3% of caregivers had good practice. .is study is different from a study conducted in behaviors of preventing diarrhea [19]. .e difference might Nigeria, where 93% respondents were aware of diarrhea and be due to level of awareness, educational status, socio- had understanding on it [24]. .is might be due to care- demographic factors, and others. .e finding is higher than givers’ lack of prior experience, educational status, and findings of studies conducted in Fagita Lekoma district source of information. (37.6%) [19], South Sudan (42.2%) [20], and Finote Selam .e key strengths of the study were the design which is town (45.9%) [6]. community based and involvement of adequate sample size. In this study, housewife caregivers were 3.9 times more .e basic limitations of the study were difficulty to know the likely to practice diarrhea prevention in under-five children cause and effect, at the same time resulted from its nature of than merchants and others (AOR: 3.922, 95% CI: 1.593, cross-sectional study and under or over reported depending 9.657). .is is supported by the study done in Iran, where on the recent health-care workers activity because they Journal of Environmental and Public Health 7 might think of that children could receive medical attention Biology, Agriculture and Healthcare, vol. 7, no. 4, pp. 3–10, through the study. 2016. [3] Y. Mumtaz, M. Zafar, and Z. Mumtaz, “Knowledge attitude 5. Conclusion and practices of mothers about diarrhea in children under 5 years in karachi hospital, Pakistan,” Journal of Dow University .e result of this study showed that diarrhea prevention of Health Sciences, vol. 8, no. 1, pp. 3–6, 2014. practice among under-five children caregivers was low, and [4] T. Dodicho, “Knowledge and practice of mothers/caregivers the practice of diarrhea prevention practice was significantly on home management of diarrhea in under five children in associated with information on frequency of diarrhea, oc- Mareka district, Southern Ethiopia,” Journal of Health, cupation, and family size in a house. Stakeholders have to Medicine and Nursing, vol. 27, no. 2422–8419, pp. 71–79, 2016. [5] D. Amare, B. Dereje, B. 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Gasana, “Prevalence of diarrhoea and associated factors among under-five children in Jigjiga Ethical Approval district, Somali region, Eastern Ethiopia,” Open Journal of Preventive Medicine, vol. 6, no. 10, pp. 233–246, 2016. Debre Markos University Research Ethics Review Com- [8] A. Abebaw, “Awoke worku & TM: crossectional survey; as- mittee reviewed the ethical acceptability of the research. sessment of diarrheal disease prevalence and associated fac- tors among children under five in enemay district, Northwest Consent Ethiopia,” Global Journals Inc (USA), vol. 14, no. 3, pp. 17–21, 2014. Informed consent was obtained from each participant [9] M. Khalili, M. Mirshahi, A. Zarghami, M. Rajabnia, and during data collection. F. Farahmand, “Maternal knowledge and practice regarding childhood diarrhea and diet in Zahedan, Iran,” Health Scope, Conflicts of Interest vol. 2, no. 1, pp. 20–23, 2013. 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